Staff Training Reduces Postpartum Bleeding, Episiotomies
WEDNESDAY April 30, 2008 -- An intensive educational program for physicians and midwives that stresses giving women the drug oxytocin just after a vaginal delivery resulted in significantly fewer cases of excessive bleeding, according to a study done in two South American countries.
Oxytocin helps contract the uterus and stop uterine bleeding. If the uterus fails to contract after detachment of the placenta, or ruptures or tears in the uterus and other tissues occur during birthing, postpartum hemorrhage can occur.
The education program, involving 19 hospitals in Argentina and in Uruguay, also resulted in fewer episiotomies being performed. While still a common procedure worldwide, many studies have shown that an episiotomy -- the surgical cutting of the skin between the vagina and anus -- is not beneficial in preventing tearing of the vagina during the birth process.
"It can be difficult to change accepted medical practices," Duane Alexander, director of the National Institutes of Health's Eunice Kennedy Shriver National Institute of Child Health and Human Development. "This successful intervention offers an effective model that can be translated into education programs suitable for interventions throughout the United States and Latin America."
The results of study were expected to be published in the May 1 issue of the New England Journal of Medicine.
The educational program sent up to six staff-selected "opinion leaders" at 10 public maternity hospitals in Argentina and Uruguay to a five-day workshop about developing and applying guidelines for physicians and midwives based on the best available scientific evidence. Instruction of techniques to hasten expulsion of the placenta and bring on uterine contractions that stop bleeding following detachment of the placenta were also taught.
The opinion leaders also then trained how to best communicate their new guidelines and techniques to their hospitals' other physicians, midwives, and others who aid in birthing.
At the end of 18 months, the researchers looked at records on the 5,466 vaginal births that took place at the 10 hospitals using the new guidelines and nine control hospitals where no new birthing recommendations were made. Oxytocin use rose from 2.1 percent of births to 83.6 percent at the 10 hospitals participating in the workshops. Oxytocin use increased only from 2.6 percent to 12.3 percent at the control hospitals.
Episiotomies dropped from 41.1 percent of births to 29.9 percent at hospitals receiving the staff instruction; they rose slightly -- from 43.5 percent to 44.5 percent -- at the control hospitals.
The hospitals where the staff received the instruction also had a 45 percent reduction in postpartum hemorrhages of 500 milliliters (2 cups) or more, and a 70 percent reduction on postpartum hemorrhage of 1,000 milliliters (4 cups) or more.
After a year, oxytocin use remained high (73.4 percent) at hospitals participating in the workshops instruction and low in control hospitals (7.1 percent). Also, the episiotomy rate at hospitals receiving the instruction remained relatively stable at each.
Given the results, the researchers suggested that getting health professionals to adopt a new practice (using oxytocin) may be easier than getting them to eliminate an established practice (episiotomy use).
The Agency for Healthcare Research and Quality has more about having an episiotomy.
Posted: April 2008
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